Open fracture ER Management

Gustilo Anderson Classification of Open fracture

Progression for grade I to III C implies a higher degree of energy involved in the injury, higher soft tissue and bone damage, and higher portential for complications.

open fracture gustilo anderson

Type I: <1 cm; Mild/minimal energy trauma, soft tissue injury, contamination or communition

Type II: 1-10 cm; Moderate energy trauma, soft tissue injury, contamination or communition

Type III: >10 cm; Severe/extensive energy trauma, soft tissue injury, contamination or communition or segmental fractures

These are automatically Type III open fractures:

  1. Fractures >8 hours old
  2. Farmyard injuries
  3. Gunshot injuries
  4. Traumatic amputation
  • III A: Adequate soft tissue coverage of bone
  • III B: Bony exposure
  • III C: Compromise of neurovascular status

gustilo anderson type III

Mangled Extremity Severity Score (MESS) to Predict Eventual Amputation

Mnemonic: MESS

1. Maturity (Age):

  • <30 years: 0
  • 30-50 years: 1
  • >50 years: 2

2. Extremity ischemia:

  • Pulse reduced or absent but perfusion normal: 1
  • Pulseless (by doppler), paresthesia, diminished capillary refilling, diminished motor activity: 2
  • Pulseless, cool, paralysed, insensate, numb, without capillary refill: 3

3. Skeletal and soft tissue injury:

  • Low energy: 1
  • Medium energy: 2
  • High energy: 3
  • Very high energy (crush): 4

4. Shock:

  • Normotensive: 0
  • Transient hypotension: 1
  • Persistent hypotension: 2


  • Score is doubled for ischemia >6 hours.
  • MESS >7 predicts eventual amputation.

Emergency Room Management of Open fracture

Follow the trauma protocol and stabilize the patient with primary survey followed by secondary survey.

1. Prevention of further contamination:

  • Take wound swab cultures
  • Photograph the wound
  • Cover the wound with sterile dressing soaked in saline or povidone-iodine

2. Prevention of bacterial growth:

  • 6 hour golden rule: All open fractures should be regarded as surgical emergencies and shouldbe definitively treated within 6 hours of injury. But the current evidences suggest that operative care may be delayed upto 24 hours.
  • Empirical IV antibiotics in maximum dose:
    • Type I and II injuries: 1st generation cephalosporin
    • Type III injuries: Add aminoglycoside
    • Suspected anaerobic contamination: Add metronidazole

Rule of 3 for antibiotics: Initiate antibiotics as soon as possible (possibly within 3 hours) and continue for atleast 3 days.

Tetanus Prophylaxis

tetanus prophylaxis

Reference: Frontiers in Fracture Management By Timothy D Bunker, Christopher L Colton, John K Webb

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